Healthcare Provider Details

I. General information

NPI: 1629768916
Provider Name (Legal Business Name): JARED EMERSON DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/10/2023
Last Update Date: 06/27/2026
Certification Date: 06/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15777 NORTHLINE RD
SOUTHGATE MI
48195-2385
US

IV. Provider business mailing address

15777 NORTHLINE RD
SOUTHGATE MI
48195-2385
US

V. Phone/Fax

Practice location:
  • Phone: 734-246-8100
  • Fax:
Mailing address:
  • Phone: 734-246-8100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number5151016183
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: